Transition of School Based Health Center Benefit and Population into Medicaid Managed Care

Note: Benefit Transition Date no sooner than April 1, 2025

April 2025 Implementation

  • Document is also available in Portable Document Format (PDF)

April 2025                www.health.ny.gov/mrt                Office of Health Insurance Programs

Table of Contents

Overview of Transition

  1. Definitions
  2. Scope of the School Based Health Center Benefit
  3. Transitional Care
  4. SBHC/Sponsor Responsibilities
  5. MMCP Responsibilities
  6. SBHC Billing and Reimbursement
  7. Confidentiality
  8. Contracting
  9. Continuity of Services

Overview of Transition

Effective April 1, 2025, the provision of School-Based Health Center (SBHC) and SBHC-Dental (SBHC-D) services will be incorporated into the Mainstream Medicaid Managed Care (MMC) and HIV Special Needs Plan (HIV SNP) (herein referred to as MMCPs) benefit package. MMCPs will be responsible for reimbursing SBHC operators for SBHC services provided to MMCP enrollees. The goal of the transition is to maintain access to these critical SBHC and SBHC-D services while integrating the services into the larger health care delivery system. It is anticipated that the integration of SBHC and SBHC-D services within the existing managed care framework, and coordination of services with the child’s Primary Care Provider (PCP), will improve quality and promote an efficient, effective delivery system. Maintaining the continuity of care, as well as the wellness of the child, to facilitate learning and improve school attendance is of utmost importance in this transition.

The following guidelines identify the scope of benefits, the roles and responsibilities of MMCPs and SBHCs, network responsibilities, and claims coding.

The policies outlined in this document were developed with significant input from both SBHCs and MMCPs. This input will guide the transition of SBHC services into MMC over a two-year period. It is recognized; however, that certain policies may require modification during the transition and that there may be updates to this document, as necessary. The New York State (NYS) Department of Health (the Department) will continue to consult with SBHC and MMCP stakeholders regarding program policy during, and subsequent to, the transition to ensure that the goals of maintaining access to services, improving integration, continuity of care, and promoting quality improvement and efficiency in care delivery are met.

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I. Definitions

Medicaid Managed Care Plan (MMCP) is a Health Maintenance Organization (HMO), or Prepaid Health Services Plan (PHSP) certified by the Department under Article 44 of the Public Health Law, that is responsible for the provision of comprehensive covered health services to eligible persons residing within the MMCP’s contracted service area.

SBHC Operators are licensed Article 28 facilities whose extension clinics (i.e., SBHCs) provide direct service. SBHC operators are responsible for the administration and operation of SBHCs, ensuring that policies and procedures are in accordance with the New York StateSBHC Principles and Guidelines Document.

Memorandum of Understanding (MOU) Requirement is a formal written agreement between the governing authority of the school district and the Article 28 facility that is operating the SBHC which serves the students within the school. In order for an SBHC or SBHC-D program to operate in NYS, the Article 28 operators must have an MOU with the school where the clinic will be located. In New York City, the Article 28 operator must have an MOU with the New York City Department of Education.

School-Based Health Centers (SBHCs) are clinics operated by a facility licensed under Article 28 of the Public Health Law and located within a school building.

School-Based Dental Health Centers (SBHC-Ds) are clinics operated by a facility licensed under Article 28 of the Public Health Law that provide dental services within a school building or campus (i.e., Mobile Vans). SBHC-D services may be provided at dental-only SBHC-D sites or may be provided in combination with other health care services at an SBHC site.

SBHC Services include both core and enhanced services provided by SBHCs pursuant to their operating certificate. In accordance with the Department’s guidelines, all SBHCs are required to provide a core of basic primary and preventive care services including: health maintenance/well child care; diagnosis and treatment of injury and acute illness; and diagnosis and management of chronic disease. In addition, SBHCs may provide enhanced services and health education as outlined in the New York State SBHC Principles and Guidelines Document.

SBHCs that do not offer behavioral health or family planning and reproductive health services on-site in the SBHC are required to provide referrals for those services. Prior authorization is not required for behavioral health or family planning and reproductive health services.

Free Access for Family Planning and Reproductive Health Services means MMCP enrollees may obtain family planning and reproductive health services, and HIV testing and pre-and post-test counseling when performed as part of a family planning and reproductive health encounter, from either the MMCP or from any qualified Medicaid health care provider of the enrollee’s choice. No referral from the PCP or approval by the MMCP is required to access such services.

SBHC-D Services include oral health education and diagnostic and preventative treatment, such as comprehensive oral exams, x-rays, oral prophylaxis, fluoride, sealants, restorations, and extractions.

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II. Scope of the School Based Health Center Benefit

  1. MMCPs will cover services provided by SBHCs and SBHC-Ds.
  2. Students enrolled in MMCPs will have direct access to all services provided by SBHCs and SBHC-Ds, without the need for referral or prior authorization, with the following exceptions:
    1. Dental Health: Routine preventive services, such as, sealants, fillings, fluoride treatments, simple extractions (which includes the elevation and/or forceps removal of an erupted tooth or an exposed root) and cleanings provided in SBHC-D sites do not require prior authorization. MMCPs may choose to require prior authorization for dental services that include more extensive care, such as root canals, crowns, dentures, fixed partial dentures, impactions and surgical extractions, and orthodontic treatment. SBHC-D programs that provide these additional services should consult with MMCPs and/or dental benefit vendors for plan-specific requirements.
  3. During the two-year transition period, MMCPs may not require concurrent review authorization, or conduct retrospective utilization review, for SBHC services.
  4. SBHCs and MMCPs will work collaboratively on quality improvement initiatives, including information sharing to improve outcomes for an individual child.
  5. The MMCP and SBHC will develop a process to share information relating to the provision of services to children. The MMCP will work with the SBHC, and the child’s PCP (if not the SBHC), to assist in promoting wellness and ensuring that all children receive recommended well child visits and other needed services.
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III. Transitional Care

  1. During the transition of SBHC services into MMC, it is expected that the provision of SBHC and SBHC-D services to students will be maintained.
    1. The Department will assess the status of contracting efforts between SBHCs and MMCPs, and overall network readiness 90 days prior to the implementation date and take corrective action, if necessary.
    2. For SBHCs and SBHC-Ds that do not have executed contracts after 90 days of having completed all necessary documentation, and do not have executed contracts with MMCPs at the time of the implementation date, each party will continue to demonstrate good faith and participation in the process to contract for SBHC/SBHC-D services. During this continued negotiation period, the parties will mutually agree to one of the following payment mechanisms:
      1. the MMCP will reimburse the SBHC/SBHC-D retrospectively to the date the provider is approved for enrollment in the MMCP without regard to timely filing requirements; or
      2. the SBHC/SBHC-D will bill the MMCP and be reimbursed concurrently using a single case agreement on an out of network basis for services provided by the health professional until the date MMCP network participation is established.
    3. The requirements in 1(a) and 1(b) above apply to MMCPs and their sub-contracted benefit management vendors.
  2. MMCPs will permit enrollees who are in an on-going course of treatment at an SBHC at the time of the transition of these services to MMC, to continue their course of treatment unchanged for six (6) months.
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IV. SBHC/Sponsor Responsibilities

SBHC and SBHC-D operators will be required to contract with all MMCPs in their service area. For benefits managed by subcontractors, such as dental and behavioral health, the operator will be required to contract with those subcontractor(s) identified by the MMCP. Federally Qualified Health Centers (FQHCs) are encouraged, but not required, to contract with all MMCPs in their service area. For visits that are either unpaid or occur outside a contract between the FQHC and MMCP, NYS will reimburse the FQHC at the full FQHC rate, per the Department’s Managed Care Supplemental Payment Program for FQHCs Policy Document.

  1. SBHCs and SBHC-Ds will work with the Article 28 facility to have their SBHC staff credentialed.
  2. SBHCs and SBHC-Ds will share the roster of students enrolled in the SBHC/SBHC-D with the appropriate MMCPs to help determine which students are in need of a comprehensive physical exam and/or other services.
  3. SBHCs and SBHC-Ds will obtain all consents needed in order to provide services.
  4. SBHCs will be required to provide member health record information to MMCPs as needed specifically for reports required by the Department, or any designee of the Department of Health for Quality Assurance Reporting Requirements (QARR).
  5. SBHCs will assist MMCPs in improving required performance measures.
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V. MMCP Responsibilities

  1. MMCPs will contract with all Article 28 SBHC/SBHC-D operators in their service area who are willing to contract with the MMCP. MMCPs operating in any borough of New York City will contract with all Article 28 operators of SBHC/SBHC-D services in New York City who are willing to contract with the MMCP. For children living away from home for extended periods of time, the MMCP and Article 28 operator may consider executing a single case agreement where the child is located. MMCPs will assist SBHCs in securing necessary contracts with the MMCPs subcontracted benefit vendors.
  2. MMCPs will work with SBHCs to improve enrollee health outcomes.
    1. MMCPs will use rosters provided by SBHCs and SBHC-Ds to identify enrollees that are in need of physical exams or other services.
    2. MMCPS will provide data to SBHCs to help SBHCs target enrolled children who do not have an annual history and physical exam and/or other well child services.
  3. MMCPs must have a process in place to ensure that timely credentialing of SBHC providers will occur in compliance with the Medicaid Managed Care/HIV Special Needs Plan/ Health and Recovery Plan Model Contractand NYS Public Health Law §4406- d(1)(a). MMCPs will accept an Article 28 operator's credentialing of an SBHC/SBHC-D provider. Once credentialed or provisionally credentialed, as per NYS Public Health Law §4406-d(1)(a), the MMCP and the SBHC/SBHC-D will mutually agree to one of the following payment mechanisms, or the Department will establish a mechanism to ensure timely and appropriate payment for SBHC/SBHC-D services, through an individualized corrective action plan established with the MMCP:
    1. the MMCP will reimburse the SBHC/SBHC-D retrospectively for covered services provided from the provider's Medicaid fee-for-service (FFS) enrollment begin date as approved by OHIP to the date network participation is established, without regard to timely requirements; or
    2. the SBHC/SBHC-D will bill and be reimbursed by the MMCP concurrently on an out of network basis for services provided by the health professional to the MMCP's enrollees effective with the date the application is received by the MMCP, until the date network participation is established.
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VI. SBHC Billing and MMCP Reimbursement

  1. SBHCs and SBHC-Ds will submit claims to MMCPs for all SBHC and SBHC-D services provided to MMCP enrollees.
  2. All claims submitted by SBHCs must have a valid primary diagnosis noted on the claim.
  3. MMCPs must reimburse pursuant to a contract between the MMCP and FQHC SBHC and/or SBHC-D. MMCPs must reimburse Article 28 non-FQHC SBHC and SBHC-D operators at the current applicable Medicaid FFS rates for two years after the implementation of the transition to managed care as outlined in the NYS MainstreamMedicaid Managed Care and School-Based Health Center Billing Guidance.
  4. Article 28 FQHCs that participate in the Supplemental Payment Program and have SBHC/SBHC-D will have the wrap rate code 1609 loaded to those sites and should bill rate code 1609 for eligible visits per the New York State Department of Health’s NYS Managed Care Supplemental Payment Program for FQHCs Policy Document.
  5. All SBHC/SBHC-D operators other than FQHCs will be reimbursed at their NYS Medicaid FFS rate (APG/PPS).
  6. For dental and mental health benefits managed by a MMCP through a sub-contractual relationship, the SBHC may be required to directly bill the subcontractor as indicated by the MMCP.
  7. Billing and reimbursement for services provided by SBHCs and SBHC-Ds to MMCP enrollees will occur in accordance with the NYS Mainstream Medicaid Managed Care and School-Based Health Center Billing Guidance.
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VII. Confidentiality

  1. Per the Department’s Policy for the Protection of Confidential Health Information for Minors Enrolled in NYS Medicaid Managed Care Plans MMCPs are required through federal and NYS statute and regulations to prevent unauthorized disclosure of their enrollees’ protected health information. Minors are entitled to the same, or stricter, confidentiality protections for certain services or under certain conditions. These include, but are not limited to, the Health Insurance Portability and Accountability Act; 42 CFR §2.14; NYS Public Health Law §§18, 2305(2), 2306, and 2504(1); NYS Public Health Law Article 27-f; NYS Mental Hygiene Law §§22.05(b), 22.11(c), 33.13, and 33.16; 18 NYCRR §360-8; and Carey v Population Services International, 431 U.S. 678 (1977).
  2. MMCPs must accommodate an enrollee’s reasonable request to receive communications by alternative means or at an alternative location when the enrollee clearly states that disclosure could endanger them. For example, an enrollee may request that an MMCP communicate via cell phone instead of paper mail.
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VIII. Contracting

  1. Contracts will be executed between the MMCPs and the Article 28 facilities that operate the SBHCs. MMCPs that currently have provider agreements with the Article 28 operators may modify existing contracts with operating facilities to include the facilities’ SBHCs.
  2. SBHCs will be listed as approved sites for care in MMCP provider directory and promotional materials.
  3. All agreements between the operating entity and the MMCP will reflect all SBHC sites that are operated by the Article 28 facility. A separate agreement is not required for each SBHC site.
  4. If the MMCP is utilizing a previously approved contract with an Article 28 facility, the contract will not have to be submitted to OHIP for review and approval. If the contract was not previously approved, it must be submitted to OHIP prior to execution.
  5. For benefits managed by subcontractors, such as dental and behavioral health, the operator may be required to contract with the subcontractor identified by the MMCP.
  6. The designation of SBHCs as PCPs is permitted and will be determined on a case-by-case basis between the MMCPs and the SBHC operating facilities. No SBHC will be required, however, to be a PCP as a condition of participation. The MMCP designating an SBHC as PCP must ensure the SBHC maintains the responsibilities similar to those of other network PCPs. Those responsibilities include, but are not limited to, disease management, referrals, hours of availability, and access to care on a full-year basis.
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IX. Continuity of Services

  1. The Division of Family Health and OHIP will continue to work with SBHCs and MMCPs to ensure a smooth transition of SBHC and SBHC-D services and payments to ensure students have continued access to health care services.
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